Provider Demographics
NPI:1124387048
Name:SHASTRY, SHUBHA (MD, PHD)
Entity Type:Individual
Prefix:
First Name:SHUBHA
Middle Name:
Last Name:SHASTRY
Suffix:
Gender:F
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:370 E RIDGE RD
Mailing Address - Street 2:SUITE 20
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14621-1240
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:370 E RIDGE RD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14621-1240
Practice Address - Country:US
Practice Address - Phone:585-922-0400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-12
Last Update Date:2014-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY267196207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03725091Medicaid
NY01131126/RGHMedicaid
NY03725091Medicaid
NY01131126/RGHMedicaid